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�'Ra�S►�33 <br />X <br />1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAMILTON AVENUE - STOCKTON CA 95205 - (209) 488-3420 <br />NUN-KEFUNDABLE rERMITr UALL LUti WOZ-10VI FOR INSPECTIONS �CAr,IKC3 IppTEAAROFROM DATE ISSUED <br />JOB ADDRESS "1�`�+� �D`rAd�O _ _ — CITYMP S W-kAcy\ "15?Ob <br />CROSS STREET �V �r Qat APN R'5020 ZZ PARCEL SIZE TA6 RAND USE APPLICATION # <br />OWNER NAME PHONE <br />OWNER ADDRESS _ _._ CITY/STATE21P ` _ <br />CONTRACTOR �{+YQ�/���F'i{0rr1,S ��d'Ar�� S TAC. ` PHONE kN) <br />CONTRACTOR ADDRESS `U2 �c+"��""111A` WB`"i CITY/STATEMP tOZ CA �Q9240 <br />SUBCONTRACTOR fin-,` PHONNQE, JNA- - <br />SUBCONTRACTOR ADDRESS SIA AV. CITY/STATE/ZJP sowle <br />LICENSE AC -57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 46ROM EXPIRATION DATE 5-31-23 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE ❑ DomesticJPrivate 0 Irrigation/Agricultural ❑ Industrial Water Quality Monitoring �, Soil Sampling/Characterization <br />Public Water System <br />If dlffererd from Owror. Water System Name Corded Name or Phoria Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well AlterabonMlodtficabon 0 Other <br />Monitoring Well(s) # of wells L, Sol l Boring(s) # of Wrw p4 Geotechnical # of borings <br />Out -Of -Service Well Out-Of-Serv(ce Well Renewal ❑ Cross -Connection Repair <br />I&ELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ¢l Auger ❑ Cable Tool Push Point Other <br />Proposed Well Depth i5 ft Excavation y'(; in diameter 0 Open Bottom ❑ Gravel Pack/Gravel Size In diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft )d Neat Cement (94 /b bag/5-10 gal water) Sand Cement sack m1x/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped )� Free Fell 7� Other 'r e"4 t u Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor 0 Other <br />❑ Concrete Pedestal 13 Dimensions: Width ft Length ftThick <br />In ❑ Christy Box 0 Stove Pipe PAYmENT <br />PUMP ❑ Submersible[] Turbine ❑ Other HP Pump Set ft Standing Water L <br />Plot Plan Requirements: Attach a plot plan with the exact location of water well with respect to the following Items: G <br />Coordinates, property lines, adjoining properties, water bodies or courses, drainage pattern, roads, existing w"tau <br />potential sources of contamination, sewers or private disposal systems. Include distance from two property lines. For Domestic <br />Agriculture, Industrial well, provide location of any water wells or surface water within 200' radius of proposec$,MOAQUIN COLINZ <br />ENVIRONMENTAL <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRLD FOR INSPECTIONS • PLEASE ( ALL (269) 953-7697 HEALTH DEPARTMEN <br />ZTM:NT SE ONLYApplication Accepted By De --I Area L Employee ID# <br />Grout Inspection By U15 Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date _ ❑ WAIVER Rel elved <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />ft <br />EHM3-06 1025=1 Page I of 2 weu / Pump Pamir <br />I <br />s <br />�.. <br />1�MW <br />r111V-�_�iLJr�Q ' ����,►`.1�,�,irirTii�•� <br />EHM3-06 1025=1 Page I of 2 weu / Pump Pamir <br />I <br />s <br />